medical students embarking on a surgical rotation or a general surgery residency program, this operative surgery manual is invaluable. Khatri and Asensio have. Vijay P. Khatri, MD, Williamsville, NY; J.A. Asensio, MD, Division of Trauma Surgery, University of Southern California Medical Center, Los Angeles, CA. Vijay P. Khatri and Juan A. Asensio; Philadelphia, Saunders, , pages, $ ISBN Operative Surgery Manual is a well-written.
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Amazon Second Chance Pass it manul, trade it in, give it a second life. Amazon Rapids Fun stories for kids on the go. The gland is thus sequentially elevated off all the branches of the facial nerve. The superficial lobe is removed, and any persistent bleeding is controlled with bipolar electrocautery or fine ligatures.
If the deep lobe of the parotid gland also needs to be removed, several vascular structures first need to be secured. At the lower border of the deep portion of the parotid gland, the posterior facial vein is isolated, divided, and ligated with silk sutures. Next, the posterior facial vein is separated from the marginal mandibular nerve before it is divided and ligated with silk sutures. The lower border of the gland is elevated; deep to the posterior belly of the digastric muscle, the external carotid artery is divided and ligated.
Posteriorly, the superficial temporal vessels are divided. At the anterior border of the gland, the internal maxillary and transverse facial vessels are divided. The individual branches of the facial nerve are dissected free from the parotid gland and retracted gently with either nerve hooks or vessel loops.
The deep lobe is removed from the space between the divisions of the facial nerve or from below the lowermost division. The platysma is approximated with absorbable sutures. The skin is closed with subcuticular absorbable sutures. The closure can be reinforced with Steri-Strips. The buds initially give rise to cords that canalize into ducts, and their ends differentiate into the acinar structures. ANATOMY The submandibular gland is located in the floor of the mouth and consists of a larger superficial part that communicates with a smaller deep part around the posterior border of the mylohyoid.
The superficial part primarily lies within the digastric triangle and is bounded superomedially by the mylohyoid muscle, superolaterally by the mandible, and inferiorly by the skin platysma and investing layer of the deep cervical fascia.
The facial artery is related to the posterior surface of the submandibular gland. The deep part of the submandibular gland is located in the interval between the mylohyoid and the hyoglossus muscle.
Other important structures that lie in the vicinity of the deep part of the submandibular gland are the lingual nerve, the submandibular ganglion superiorly, and the hypoglossal nerve inferiorly.
The blood supply of the submandibular gland is through branches of the facial and lingual arteries, and the venous drainage follows the respective facial and lingual veins.
The parasympathetic secretomotor supply is from the superior salivary nucleus of the seventh cranial nerve. These fibers reach the submandibular ganglion via the chorda tympani and submandibular ganglion.
Although indication for resection of the submandibular gland is usually based on clinical suspicion, results of fine-needle aspiration cytology, if performed, should be reviewed. Preoperatively the surgeon must determine by physical examination whether the hypoglossal, lingual, and marginal mandibular branches of the facial nerve are intact. Informed consent is obtained after the patient is informed about the risks of damage to the hypoglossal nerve, the lingual nerve, and the marginal mandibular branch of the facial nerve.
Operative Procedure POSITION The patient undergoes general anesthesia with endotracheal intubation, but anesthesiologists must refrain from using paralyzing agents because these may make the use of the nerve stimulator ineffective. The skin is incised with a no. Figure A, Incision used to perform submandibular gland resection. Important anatomic structures are shown. B, Mylohyoid muscle is retracted to expose the submandibular duct and lingual and hypoglossal nerves.
In line with the incision, the platysma is also divided, and then superior and inferior flaps are created in the subplatysmal plane. Superiorly, the surgeon should be cognizant of the presence of the marginal mandibular branch of the facial nerve.
The facial artery and vein will be encountered running deep to this nerve, and they are divided and ligated. In fact, retracting these vessels upward will protect the marginal mandibular branch of the facial nerve during subsequent dissection Hayes-Martin maneuver.
The superior border of the gland is freed from the body of the mandible. Posteriorly, the gland is carefully elevated off the surface of the sternocleidomastoid muscle.
Retracting the anterior border of the sternocleidomastoid muscle will expose the tortuous facial artery, which is ligated again. The superficial part of the submandibular gland is elevated from the underlying mylohyoid muscle. The posterior border of the mylohyoid muscle is identified and then retracted anteriorly with a loop retractor. This should expose the deep part of the submandibular gland and the important adjacent structures Fig. These include the lingual nerve above and the hypoglossal nerve below.
Superiorly the branches from the lingual nerve to the submandibular ganglion are seen and divided. This allows the lingual nerve to retract superiorly and thus avoids injury. Next, the hypoglossal nerve, which will be seen emerging from beneath the anterior belly of the digastric muscle, is identified.
The submandibular duct is clamped, divided, and ligated with absorbable sutures. The operative area is inspected for hemostasis, and the retracted marginal mandibular nerve is returned to its normal position. The platysma is approximated, with care taken not to entrap the already preserved marginal mandibular nerve. The skin is closed with absorbable sutures.
The neck is extended by placing a rolled sheet beneath the shoulder. The head is rotated toward the opposite side. The patient is placed in the reverse Trendelenburg position, which aids in reducing the venous pressure. We have used the hockey-stick incision, which commences at the mastoid process, runs obliquely downward along the anterior border of the sternocleidomastoid muscle, and gently curves into a horizontal limb.
The platysma is divided down to the enveloping layer of the deep cervical fascia. To facilitate creation of the flaps, the assistant can use skin hooks to retract the skin upward. While countertraction is applied, the superior flap is elevated in the subplatysmal plane to the level of the mandible.
Approximately 1 to 1. The greater auricular nerve is identified and preserved by dissecting superficially to the nerve. Superiorly where the platysma thins out, the plane of dissection is kept on the surface of the sternocleidomastoid muscle. The posterior flap is elevated until the anterior border of the trapezius muscle is identified. The dissection proceeds inferiorly to the clavicle and medially to the midline. Posterior triangle dissection is started by skeletonizing the full length of the anterior border of the trapezius.
Along the lower half of the trapezius the spinal accessory nerve is identified and transected. The free edge of the areolar tissue is grasped with multiple clamps to allow the assistant to provide upward retraction while it is elevated from the floor of the posterior triangle. The splenius capitis, levator scapulae, and scalenus medius are exposed Fig. As medial dissection is continued, the sensory and motor roots of C2 and C3 will be encountered.
The sensory roots are divided, and the motor roots are preserved. Further distal dissection deep to the sternocleidomastoid muscle should be avoided because the phrenic nerve can be injured. Figure A, The muscles of the posterior triangle and the cervical sensory and motor roots are exposed.
SCM, Sternocleidomastoid. B, The internal jugular vein has been divided and the specimen is carefully freed from the carotid sheath. Dissection is proceeding toward level I. Next, at the base of the posterior triangle the transverse cervical vessels are isolated, ligated, and divided. The inferior belly of the omohyoid muscle is identified, clamped, and divided. The heavy clamp is left on the proximal end of the omohyoid muscle to facilitate further dissection.
Finally, the fibroadipose tissue containing lymphatics above the clavicle base of posterior triangle is carefully clamped, divided, and ligated. The external jugular vein is divided and ligated. The sternal and clavicular attachments of the sternocleidomastoid muscle are divided carefully, thus exposing the carotid sheath. Beneath it the distal end of the internal jugular vein will be seen and is also dissected, after it is ensured that the vagus nerve is not adherent.
The internal jugular vein is ligated in continuity with silk sutures and transected. A transfixion silk suture is placed on the distal stump. The specimen is retracted upward, and dissection is carefully undertaken along the carotid artery with a scalpel or electrocautery Fig.
The phrenic nerve will be seen lying on the surface of the anterior scalene muscle. As dissection proceeds cranially, it is also freed in the midline. Now, the tissue in the submental area is dissected and elevated until the entire mylohyoid muscle is exposed.
The lateral border of the muscle mylohyoid is retracted anteriorly to expose the critical structures within the submandibular triangle. Superiorly the lingual nerve will be identified with a branch to the submandibular gland. This branch is divided, which allows the lingual nerve to retract superiorly. Next, the hypoglossal nerve is identified as it is emerging from beneath the anterior belly of the digastric muscle.
Between the two nerves will be the submandibular duct of Wharton, which is clamped, divided, and ligated with absorbable sutures. The submandibular gland can thus be elevated and can then be released by dividing the facial vessels present at its posterior border.
This portion of the dissection is completed by elevating the rest of the lymphoareolar tissue off the posterior belly of the digastric muscle.
The lower pole of the parotid gland is removed, which facilitates visualization of the upper end of the internal jugular vein. The operative field after completion of the procedure is shown in Figure 6— 2. Figure Operative field at completion of procedure.
The platysma is carefully approximated with interrupted absorbable sutures, and the skin is closed with subcuticular absorbable sutures. Modified Radical Neck Dissection The position, incision, and flap elevation are similar to that described for radical neck dissection.
When modified neck dissection is performed, either all or some of the following anatomic structures are preserved: sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve. After the flaps are created, the spinal accessory nerve is identified at the anterior border of the trapezius and carefully freed along its course in the posterior triangle. The lymphoareolar tissue in the superior half of the posterior triangle is dissected from the underlying muscles and delivered beneath the previously identified spinal accessory nerve.
The inferior half of level V is then completed, the inferior belly of the omohyoid muscle is divided, and the brachial plexus is exposed. With the specimen elevated, the cervical plexus comes into view.
The cutaneous branches of the cervical plexus are divided, carefully preserving the motor nerve supply to the muscles of the posterior triangle and the contributions to the phrenic nerve. Next, the fascia along the posterior border of the sternocleidomastoid muscle is incised along its entire length, and the muscle is completely freed from its fascial coverings.
A Penrose drain is used to lift the sternocleidomastoid muscle. While the internal jugular vein is preserved, the contents of the carotid sheath are dissected upward toward the jugulodigastric area. The contents of the submandibular triangle are dissected in the usual fashion. Jackson-Pratt drains are placed, the platysma is approximated, and the skin is closed as described for radical neck dissection. This diverticulum begins to grow caudad to form the midline trachea and at its most distal portion divides into two lateral branches, the lung buds.
The right lung bud divides into three branches, forming the main bronchi, and the left divides into two main branches, thus representing the adult pulmonary lobar anatomy. During this period, the respiratory diverticulum has a wide-open connection to the foregut that begins to separate due to the formation of the tracheoesophageal septum.
The connection to the foregut is maintained only at the most proximal portion—the laryngeal orifice. The lung buds are surrounded by splanchnic mesoderm, which forms the visceral pleura.
As the lung buds further develop and repeatedly divide in a dichotomous fashion, they grow into the pericardioperitoneal canal. At the end of the sixth month, approximately 17 generations of subdivisions have formed, and at the seventh month the terminal bronchioli expand to form the alveoli.
The block of mesodermal tissue surrounding the bronchial tree differentiates into cartilage, muscle, and blood vessels. The lungs are spongy and elastic in consistency, which allows them to conform to the contours of the thoracic cavity.
Each lung has an apex directed toward the thoracic inlet and a base lying on the diaphragm. The lungs are divided into lobes by fissures, which extend deep into their parenchyma.
The oblique fissure divides the left lung into an upper lobe and a lower lobe. The oblique and horizontal fissures divide the right lung into upper, middle, and lower lobes. The anteroinferior part of the left upper lobe, lying adjacent to the cardiac notch, is known as the lingula and represents the middle lobe.
However, there can be variations in the lobar pattern; in particular, the horizontal fissure may be incomplete and occasionally additional lobes may be present.
The trachea divides into the right and left main-stem bronchi. The left upper lobe bronchus arises from the main-stem bronchus within the lung and divides into five segmental bronchi, with two passing to the lingula. The left main-stem bronchus continues into the lower lobe and divides into five segmental branches. The right upper lobe bronchus arises from the right mainstem bronchus, and soon after entering the lung it divides into three segmental bronchi. The middle lobe divides into two segmental branches.
Finally, the continuation of the right mainstem bronchus passes to the lower lobe and divides into five segmental branches.
Each segmental bronchus is distributed to a functionally independent unit of lung tissue—a bronchopulmonary segment. The bronchial branches of the descending thoracic aorta supply the lung.
The bronchial veins drain into the azygos and hemiazygos veins. Lymphatic drainage is via the superficial subpleural lymphatic plexus and a deep plexus of vessels accompanying the bronchi. Both groups drain through hilar lymph nodes to the tracheobronchial nodes around the bifurcation of the trachea and then to the mediastinal lymphatic trunks. The pulmonary plexus provides the nerve supply to the lungs and contains the sympathetic fibers from the upper thoracic segments and the parasympathetic fibers from the vagus nerve.
Positron emission tomography is now becoming the standard of care to assess for extrapulmonary metastases. Pulmonary function tests should have been obtained to determine whether the patient has adequate lung capacity to tolerate certain resections.
A Foley catheter, a central venous catheter on the side of the thoracotomy, and a radial artery catheter on the side opposite the thoracotomy are placed. General anesthesia is administered with the use of a double-lumen endobronchial tube. The patient is prepped and draped.
INCISION A posterolateral thoracotomy incision is made beginning posteriorly midway between the spinous process of the vertebrae and the medial border of the scapula, extends one to two fingers-breadth below the tip of the scapula, and is continued forward below the level of the nipple. The auscultatory triangle is identified, and the fascia is divided to allow the surgeon to pass two fingers below the chest wall muscles Fig.
The latissimus dorsi posteriorly and the serratus anterior muscle anteriorly are divided with electrocautery Fig. A scapula is lifted to count the ribs after the first or second rib is identified. The fifth intercostal space is chosen, and the intercostal muscles along the upper border of the sixth rib are divided with electrocautery Fig. Before the surgeon enters the thoracic cavity, the ipsilateral lung is collapsed by the anesthesiologist to avoid injury.
A careful exploration of the thoracic cavity is performed to inspect for presence of pleural implants, pleural effusion, and enlarged mediastinal lymph nodes. If the thoracotomy is for resection of a lung tumor, this lesion is identified and any extension of this lesion into the hilum or mediastinal structures is also defined.
Dissection begins by opening the mediastinal pleura and carefully dissecting and identifying the main pulmonary artery and both the superior and inferior pulmonary veins. Vessel loops are placed around these vessels. Figure A, Muscles encountered when the thoracotomy incision is performed. The auscultatory triangle can be seen. B, Muscles have been divided, and the fifth rib is identified. C, The fifth intercostal space is chosen and the intercostal muscles along the upper border of the sixth rib are divided with electrocautery.
The intercostal neurovascular bundle can be seen beneath the lower border of the rib. Right Pulmonary Resections The initial step is to identify the azygos vein, which is ligated in continuity with silk sutures and divided.
Just inferior to the angle between the azygos vein and the superior vena cava, the main pulmonary artery can be located. Using a meticulous combination of sharp and blunt dissection, the operator places a vessel loop around the main pulmonary artery. Just inferior to the main pulmonary artery, the superior pulmonary vein is identified and carefully dissected, and a vessel loop is placed around it. More inferiorly, the inferior pulmonary ligament is carefully divided with Metzenbaum scissors or electrocautery.
The inferior pulmonary vein is identified, and a vessel loop is placed around it. First, the anterior and apicoposterior segmental branches of the main pulmonary artery to the upper lobe are ligated in continuity with silk sutures, divided, and transfixed proximally with silk suture ligatures.
Within the major fissure, the posterior segmental branch of the upper lobe is identified, ligated, transfixed, and divided in a similar fashion.
Within the minor fissure that exists between the upper and middle lobes, the pulmonary venous drainage from the upper lobe is identified and carefully dissected.
The vein is ligated in continuity with 0 silk sutures, transfixed with silk suture, and divided. At this point, the lung is retracted forward to gain access to the posteriorly placed bronchus. The right main-stem bronchus and the carina are identified. The upper lobe bronchus is identified and transected with a TA stapler.
In this fashion, the right upper lobectomy is completed. Right Middle Lobectomy For a right middle lobectomy, the pulmonary artery branch to the middle lobe is identified, ligated with silk sutures, transfixed with silk sutures, and divided.
The middle lobe division of the superior pulmonary vein is similarly ligated with silk sutures, transfixed with 20 silk sutures, and divided. With these two vessels addressed, the surgeon carefully isolates the middle lobe bronchus and then transects it with a TA stapler. Right Lower Lobectomy To perform a right lower lobectomy, the main pulmonary artery is followed in the major fissure, and the segmental branches to the lower lobe are identified.
The superior and basal segmental branches to the lower lobe are carefully identified, ligated in continuity with 0 silk sutures, transfixed with silk sutures, and divided. Particular care is taken to avoid injury to the middle lobe arteries. Next, attention is directed to the inferior pulmonary vein, where, after the surgeon has ensured that any drainage from the middle lobe is protected, the inferior pulmonary vein is transected with a TA stapler.
Again, within the same major fissure, the superior segmental and the basal segmental bronchi are individually identified and transected with a TA stapler. Right Pneumonectomy If the surgeon decides to perform a pneumonectomy to ensure complete resection of the tumor, this is fairly straightforward because dissection of all the primary vessels has already been performed. With the use of a TA stapler, the pulmonary artery and then the superior and inferior pulmonary veins are transected.
The lung is retracted anteriorly, and the right main-stem bronchus is carefully isolated and transected with a TA stapler, taking care to avoid compromising the lumen of the left main-stem bronchus. Left Lung Resection After a thorough exploration of the left thoracic cavity is performed, the mediastinal pleura is carefully divided. After identification and preservation of the phrenic, vagal, and recurrent laryngeal nerves, the superior pulmonary artery and the superior and the inferior pulmonary veins are individually dissected and vessel loops are placed.
To perform a lobectomy, the pulmonary artery is followed distally, which leads into the major fissure. The individual segmental branches of the pulmonary artery to the appropriate upper or lower lobe are carefully dissected, ligated in continuity with silk sutures, and transfixed with silk sutures.
Alternatively, these vessels can be transected with either an endovascular stapler or a TA stapler. Finally, the appropriate draining pulmonary vein is dissected and transected with a TA30 stapler. With the pulmonary vein and the artery having been addressed, the underlying bronchus is exposed, which can be transected with a TA stapler. If a left pneumonectomy is being performed, the pulmonary artery, pulmonary vein, and main-stem bronchus are stapled individually.
After the lung resection is completed, the lung is inflated and any leaks are closed with or 40 absorbable sutures. Through two separate stab incisions, two chest tubes are inserted: One is directed to the apex size 36 Fr and the other toward the costophrenic sulcus size 32 Fr curved.
These are secured with nonabsorbable sutures. The chest tubes are connected to a water seal and suction is applied. A Bailey rib approximator is helpful during the process of rib approximation.
Latissimus dorsi and serratus anterior muscles are aligned and approximated with interrupted silk sutures. The skin is approximated with staples. Elongation of the esophagus occurs due to the rapid growth of the body, particularly the adjacent lung and heart. The surrounding mesenchymal tissue forms the muscular covering of the esophagus. ANATOMY This is a tubular structure measuring 25 cm that begins just behind the cricoid cartilage at the level of the sixth cervical vertebra as a continuation of the pharynx.
The upper end is approximately 15 cm from the incisors. The esophagus descends through the neck and posterior mediastinum to pass through the diaphragm at the level of T10 to join the stomach in the abdomen. In the neck, the esophagus lies anterior to the prevertebral fascia and posterior to the trachea, and in the groove between these structures lie the important recurrent laryngeal nerves.
Laterally, the esophagus is related to the thyroid lobes and the carotid sheath. Upon entering the thoracic cavity, the esophagus initially lies on the left side and is subsequently pushed to the midline by the aortic arch.
The esophagus then crosses the midline and assumes a right-sided position within the right thoracic cavity. Before piercing the diaphragm, the esophagus is displaced toward the left and is found anterior to the descending thoracic aorta.
Posteriorly and starting from above downward, it is related to the thoracic duct, the hemiazygos vein, the right posterior intercostal arteries, and finally the descending aorta. Below the trachea, the esophagus is crossed anteriorly by the left main-stem bronchus and then the pericardium, which separates it from the atrium. The mediastinum is present on the lateral aspect bilaterally.
On the right side the azygos vein arches forward above the lung root. On the left side it is separated from the mediastinal pleura by the left subclavian artery, the thoracic duct, the aortic arch, and the descending aorta. As the esophagus passes through the right crus of the diaphragm, it lies on the left of the midline.
It is accompanied through the hiatus by the vagi the left vagus lies anteriorly and the right vagus lies posteriorly and lymphatics. The abdominal esophagus measures approximately 3 cm in length and is covered anterolaterally by the peritoneum. The left lateral lobe of the liver is present anteriorly.
The blood supply of the esophagus is as follows: upper one third, inferior thyroid artery; middle one third, descending thoracic aorta; and lower one third, left gastric artery. The respective venous drainage for the esophagus occurs via the inferior thyroid, azygos, and left gastric veins. Similarly, the lymphatic drainage from the upper third is to the deep cervical lymph nodes, from the middle third is to the posterior mediastinal lymph nodes, and from the distal third is to the celiac axis.
A preoperative barium swallow is performed. To accurately assess the extent and anatomic location of the tumor, an upper gastrointestinal endoscopy is performed.